Assessing Walking Programs in Fibromyalgia: A Concordance Study between Measures.

This study analyzes the degree of agreement between three self-report measures (Walking Behavior, WALK questionnaire and logbooks) assessing adherence to walking programs through reporting their components (minutes, rests, times a week, consecutive weeks) and their concordance with a standard self-report of physical activity (IPAQ-S questionnaire) and an objective, namely number of steps (pedometer), in 275 women with fibromyalgia. Regularized partial correlation networks were selected as the analytic framework. Three network models based on two different times of assessment, namely T1 and T2, including 6 weeks between both, were used. WALK and the logbook were connected with Walking Behavior and also with the IPAQ-S. The logbook was associated with the pedometers (Z-score > 1 in absolute value). When the behavior was assessed specifically and in a detailed manner, participants' results for the different self-report measures were in agreement. Specific self-report methods provide detailed information that is consistent with validated self-report measures (IPAQ-S) and objective measures (pedometers). The self-report measures that assess the behavioral components of physical activity are useful when studying the implementation of walking as physical exercise.

Predicting Abusive Behaviours in Spanish Adolescents' Relationships: Insights from the Reasoned Action Approach.

(1) Background: Partner violence prevention programmes do not produce the expected behavioural changes. Accordingly, experts suggest applying evidence-based behavioural models to identify the determinants of abusive behaviours. In this research, we applied the reasoned action approach (RAA) to predict the performance (boys) and acceptance (girls) of abusive behaviours in adolescents. (2) Method: We designed a questionnaire based on the RAA and performed a cross-sectional study. We analysed the predictive capacity of the RAA constructs on intentions with the sample of single adolescents (n = 1112). We replicated the analysis only with those who were in a relationship (n = 587) and in addition analysed the predictive capacity of intention on future behaviour (3 months later). (3) Results: The hierarchical regression analysis performed with the sample of single adolescents showed that the model explained 56% and 47% of the variance of boys' intentions to perform the controlling and devaluing behaviours, respectively; and 62% and 33% of girls' intention to accept them. With those in a relationship, the model explained 60% and 53% of the variance of boys' intentions to perform the controlling and devaluating behaviour, respectively, and 70% and 38% of girls' intention to accept them. Intention exerted direct effects on boys' performance of controlling and devaluing behaviours (31% and 34% of explained variance, respectively) and on girls' acceptance (30% and 7%, respectively). (4) Conclusions: The RAA seems useful to identify the motivational determinants of abusive behaviours, regardless of adolescents´ relationship status, and for their prediction. Perceived social norms emerge as a relevant predictor on which to intervene to produce behavioural changes with both sexes.

Pain-Related Worrying and Goal Preferences Determine Walking Persistence in Women with Fibromyalgia.

Physical activity and exercise are relevant behaviors for fibromyalgia health outcomes; however, patients have difficulties undertaking and maintaining an active lifestyle. With a cross-sectional design, this study explored the role of pain-related worrying and goal preferences in the walking persistence of women with fibromyalgia. The sample included 111 women who attended a tertiary health setting. We adapted the Six-Minute Walk Test where participants decided either to stop or continue walking in five voluntary 6 min bouts. Women who were categorized higher in pain-related worrying reported higher preference for pain avoidance goals (t = -2.44, p = 0.02) and performed worse in the walking task (LongRank = 4.21; p = 0.04). Pain avoidance goal preference increased the likelihood of stopping after the first (OR = 1.443), second (OR = 1.493), and third (OR = 1.540) 6 min walking bout, and the risk of ending the walking activity during the 30 min task (HR = 1.02, [1.0-1.03]). Influence of pain-related worrying on total walking distance was mediated by goal preferences (ab = -3.25). In interventions targeting adherence in physical activity and exercise, special attention is needed for women who are particularly worried about pain to help decrease their preference for short-term pain avoidance goals relative to long-term goals such as being active through walking.

Effects of Walking as Physical Exercise on Functional Limitation through Pain in Patients with Fibromyalgia-How Does Catastrophic Thinking Contribute?

Background: Aerobic exercise has a beneficial impact on physical and mental health. However, patients with fibromyalgia do not always report perceiving these improvements. Objective: The aim of this study was to examine whether catastrophic thinking moderated the effects of perceived pain severity once an active and regular lifestyle had been established on functional limitation in chronic pain patients, in particular in fibromyalgia patients. Methods: The sample consisted of a total of 491 women with fibromyalgia diagnosed according to the criteria of the American College of Rheumatology. Participants completed an ad-hoc item about lifestyle related to walking pattern, the Brief Pain Inventory, the Pain Catastrophization Scale, and the Fibromyalgia Impact Questionnaire-Revised. To examine the relationship between the variables, a moderate mediation analysis was performed through the macro PROCESS (model 14). Results: The relationship between the performance of the recommended walking pattern and functional limitation was mediated by the severity of pain (B = −5.19, SE = 1.59, t = −3.25, 95% CI = [−4.06, −0.28], p < 0.001). Furthermore, it was found that the mediating effect of pain severity was moderated by catastrophic thinking (Index = −0.014, SE = 0.007, 95% CI [0.002, 0.030]). Conclusions: The positive effect of walking on functionality through the reduction of pain levels is favored when patients present low catastrophizing, which affects the relevance of including interventions focused on the reduction of catastrophizing in the prescription of physical exercise in patients with fibromyalgia as the treatment of choice.

Motivational Determinants of Objective Physical Activity in Women with Fibromyalgia Who Attended Rehabilitation Settings.

Being physically active has positive effects on fibromyalgia functioning. However, promoting an active lifestyle in these patients continues to be a relevant clinical challenge. Our aim was to test a motivational model to explain light (LPA) and moderate-vigorous physical activity (MVPA). A cross-sectional prospective study was conducted at a tertiary level of care. Participants completed sociodemographic, clinical, motivational (physical activity self-efficacy and goal preferences) and behavioral measures (activity avoidance). LPA and MVPA were measured with triaxial accelerometers, starting the same day of the aforementioned assessment. Out of 211 women, 183 completed this measure. Structural models were performed. Our results show that the best fit indices (CFI = 0.97, SRMR = 0.04) showed a model with direct influence of PA self-efficacy on MVPA (p < 0.01) and indirect influence on LPA (p < 0.001). LPA received the influence of PA self-efficacy mainly through activity avoidance (p < 0.01). Clinical variables did not have any effect on PA intensities. Thus, the motivational variables showed different paths to explain two PA intensities. Targeting PA self-efficacy in rehabilitation settings is needed to enhance both daily LPA and MVPA intensities.

The Activity Patterns Scale: An Analysis of its Construct Validity in Women With Fibromyalgia.

OBJECTIVES: Avoidance, persistence, and pacing are activity patterns that have different adaptive effects in chronic pain patients. Some inconsistent findings have been explained from a contextual perspective that underlines the purpose of the activity. In this way, avoidance, persistence, and pacing are multidimensional constructs, nuanced by their goals. This multidimensionality has been supported with a new instrument, the Activity Patterns Scale, in heterogeneous chronic pain samples. Owing to the clinical implications of this conceptualization, the complexity of the activity patterns and their relationships with health outcomes in fibromyalgia (FM), our aim was to explore the construct validity of this scale in this pain problem, testing its internal structure and the relationships with other constructs. MATERIALS AND METHODS: The sample included 702 women with diagnosis of FM from tertiary (53.3%) and community settings (46.7%). Confirmatory factor analysis was conducted to test different factor structures of the activity patterns and Pearson correlation to explore the relationships with health outcomes and psychosocial variables. RESULTS: A 6-factor structure showed acceptable fit indices (standardized root mean square residual=0.062; root mean-square error of approximation=0.066; comparative fit index=0.908). The highest significant relationships for health outcomes was between activity avoidance and FM impact (r=0.36) and excessive persistence and negative affect (r=0.41). DISCUSSION: Avoidance and persistence activity patterns are shown as multidimensional constructs but not pacing. The ongoing pain in these women may make it difficult to regulate their activity taking into account other goals not contingent on pain fluctuations.

Cultural Adaptation and Psychometric Properties of the Spanish Version of the Occupational Balance Questionnaire: An Instrument for Occupation-Based Research.

Occupational balance (OB) may be a major determinant of health outcomes due to its role in bringing a sense of purpose in the occupations that are personally experienced as a process of getting health and wellness. The Occupational Balance Questionnaire (OBQ) is a reliable instrument for measuring OB, although it has not been adapted and validated in Spain so far; therefore, this study had a double aim: (1) to translate and cross-culturally adapt the original OBQ version into Spanish (OBQ-E); (2) to analyze the psychometric properties for its use in the Spanish population. Standard procedures were used for the cross-adaptation process and pilot testing was carried out using three different samples to extend the applicability of the OBQ-E. Validation measures of the final version of the OBQ-E were conducted in a sample of 219 participants. The OBQ-E showed that items and instructions were culturally appropriate and written clearly. Psychometric testing showed excellent internal consistency (Cronbach's alpha = 0.87; Guttman split-half coefficient = 0.85), good test-retest reliability (rs (Spearman rho) = 0.73), and acceptable convergent validity (overall status, rs = 0.37; Related Quality of Life, rs = 0.42; Satisfaction with Life Scale, rs = 0.54). The findings suggest that the OBQ-E may be a suitable instrument for assessing OB in the Spanish population; hence, it is a promising tool for epidemiological research that will significantly contribute to the understanding of OB as a health-related factor. Nevertheless, further investigation is also warranted to explore the potentiality of this instrument for clinical purposes.

Assessing Self-Efficacy for Physical Activity and Walking Exercise in Women with Fibromyalgia.

BACKGROUND: Exercise and physical activity are an evidence-based practice for chronic pain. Health professionals need instruments to assess self-efficacy for this practice taking into account the specific barriers of patients with these health problems. PURPOSE: To develop and test the psychometric properties of a new self-efficacy scale for physical activity and walking exercise in patients with fibromyalgia. DESIGN: A cross-sectional and prospective study was conducted in a Spanish Fibromyalgia Unit. Two hundred and eleven new patients signed the informed consent and participated in the study. All of them were women, referred to by either Primary or Specialized Health Care. In addition to the new scale, they filled out several self-reported and validated instruments to collect the data present in this study. RESULTS: Exploratory factor analysis showed a three-factor model (GFI = .99; RMSR = .06) that explained 74.2% of the total variance. They assessed how confident patients felt about walking quickly in both 30- and 60-minute sessions, (Factor I: 10 items; α = .97), to perform daily physical activities (Factor II: 10 items; α = .93) and to undertake moderate physical activity (Factor III: 5 items; α = .95). The total score of the scale and the three-factor scores showed good criterion validity and adequate validity based on the relationships with other constructs. CONCLUSIONS: The scale showed adequate psychometric properties and can be a useful tool to help health professionals monitor patients' self-efficacy perception and customize both physical activity and walking exercise intervention goals and their implementation.

Contextualizing goal preferences in fear-avoidance models. Looking at fatigue as a disabling symptom in fibromyalgia patients.

The fear-avoidance model provides an explanation for the development of chronic pain, including the role of perception (i.e. pain catastrophism) as an explanatory variable. Recent research has shown that the relationship between pain catastrophism and avoidance is influenced in turn by different psychological and contextual variables, highlighting the affective-motivational ones. From this perspective, the Goal Pursuit Questionnaire (GPQ) was developed to measure the preference for hedonic goals (mood-management or pain-avoidance goals) over achievement goals in musculoskeletal pain patients. Recently, the Spanish version of the GPQ in fibromyalgia patients has been validated. Our aim has been to adapt the Spanish version of GPQ from pain to fatigue symptoms and to validate this new questionnaire (GPQ-F) in fibromyalgia. Despite the recognition of fibromyalgia as a complex disorder and the need for a differential study of its symptoms, fatigue, despite its high prevalence and limiting nature, remains the forgotten symptom. We conducted a cross-sectional study with 231 women with fibromyalgia. Previously, we adapted the Spanish GPQ for fatigue symptoms with three sub-studies (group structured interview, self-administration questionnaire and thinking-aloud; n = 15-27 patients). We explored the GPQ structure and performed path analyses to test conditional mediation relationships. Exploratory factor analysis showed two factors: 'Fatigue-avoidance goal' and 'Mood-management goal' (39.3% and 13.9% of explained variance, respectively). The activity avoidance pattern fully mediated the relation between both catastrophizing and fatigue-avoidance goals with fatigue. The study shows initial findings about the usefulness of the GPQ-F as a tool to analyze goal preferences related to fatigue in fibromyalgia. The results supported the mediational role of activity avoidance patterns in the relationship between preference for fatigue-avoidance goals and fatigue.

Activity Patterns and Functioning. A Contextual-Functional Approach to Pain Catastrophizing in Women with Fibromyalgia.

BACKGROUND: The psychological flexibility model states that activity patterns are not deemed to be intrinsically functional or dysfunctional; it is considered that underlying factors, such as personal goals and contextual factors, are what will determine their effects on disability. Pain catastrophizing has frequently been associated with several important pain-related outcomes. Despite its recent conceptualization within affective-motivational approaches, its moderating role between activity patterns and dysfunction has not been analyzed. METHODS: This study analyzes the moderating role of pain catastrophizing and its dimensions (Pain Catastrophizing Scale) between activity patterns (Activity Patterns Scale) and disease impact (Fibromyalgia Impact Questionnaire-Revised) in 491 women with fibromyalgia. RESULTS: Activity avoidance (p < 0.001), excessive persistence (p < 0.001) and pacing (p < 0.01) patterns were positively associated with fibromyalgia impact. Helplessness shows a moderating role between pain avoidance (B = 0.100, t =2.30, p = 0.021, [0.01, 0.18]), excessive persistence (B = -0.09, t = -2.24, p = 0.02, [-0.18, -0.01]), pain persistence (B = -0.10, t = -2.04, p = 0.04, [-0.19, -0.004]) and functioning. CONCLUSION: Helplessness (within pain catastrophizing) is a relevant variable within psychological flexibility models applied to activity patterns. Specifically, pain avoidance is especially dysfunctional in patients with high helplessness. To improve excessive persistence and pain persistence, it is necessary to reduce helplessness before regulating activity patterns.

Are Pacing Patterns Really Based on Value Goals? Exploring the Contextual Role of Pain Acceptance and Pain Catastrophizing in Women with Fibromyalgia.

Pain catastrophizing and pain acceptance have been associated with functioning in fibromyalgia. In relation to activity patterns, pacing has been defined as a helpful pattern to regulate activities in the context of value-based goals, but results regarding whether it is adaptive or not are controversial. This study analyzes the moderating role of pain acceptance between pain catastrophizing and pacing in 231 women with fibromyalgia. Moderation analyses were conducted with model 1 from the PROCESS Macro version 3.4. The results showed a clear moderating effect of pain acceptance. At low levels of pain acceptance, catastrophizing and pacing patterns maintained significant and positive associations. However, at high levels of pain acceptance, pacing was independent of catastrophizing. Far from considering pacing patterns as functional or dysfunctional per se, our results suggest that women with low pain acceptance carry out pacing influenced by catastrophizing independently of their goal pursuit, while patients who accept their pain may use pacing as a regulatory mechanism according to their goals.

The 4 U's Rule of Fibromyalgia: A Proposed Model for Fatigue in a Sample of Women with Fibromyalgia: A Qualitative Study.

Although fatigue usually goes unnoticed, it is a symptom that poses great challenges to patients with fibromyalgia and is a strong limitation. The aim of this study is to identify and describe the variables involved in fatigue in nine different situations of the Goal Pursuit Questionnaire (GPQ) that may occur in the daily lives of women with fibromyalgia, according to an ABC (Antecedents-Behaviors-Consequences) model. This study followed a qualitative descriptive research method and a deductive-inductive hybrid approach based on a phenomenological paradigm. Twenty-six women with fibromyalgia participated in focus group discussions between February and March of 2018. Thematic content analysis was carried out from transcribed verbatim interviews. We identified nine major themes that emerged from the participants' conversations: self-imposed duties, muscle fatigue, overwhelming feeling of tiredness, difficulty thinking, difficulty concentrating, negative emotions, lifestyle changes, affected everyday activities, and lack of motivation for daily activities and social interactions. We conclude that the ABC model allowed certain elements to emerge regarding the fatigue experience, highlighting its importance as a symptom in fibromyalgia. This additional analysis of the ABC model showed that fatigue can be described through the 4 U's Rule, which is integrated by these four adjectives: (1) Unpredictable, (2) Uncontrollable, (3) Unseen, and (4) Unintelligible. Identifying these characteristics can contribute to a better understanding of fibromyalgia in addition to better treatment for these patients.

Predicting walking as exercise in women with fibromyalgia from the perspective of the theory of planned behavior.

Based on the theory of planned behavior, this study examined factors related to the intention to adhere to an unsupervised walking program and the intention-behavior gap in relation to walking adherence in women with fibromyalgia. We also accounted for specific variables: fear of movement, pain intensity, distress and disability. TPB constructs, walking behavior and the above-mentioned variables were assessed in 274 women aged 18 to 70 years old (mean 51.8, range 25.5-69.1 years) at baseline and seven weeks later (n = 219) during 2012. Intention to adhere to a walking program showed medium scores at baseline and was associated with attitude and perceived behavioral control (PBC). Self-reported walking adherence at Time 2 was only predicted by perceived behavioral control. The intention-behavior gap was present in 33% of participants. Logistic regression analysis showed PBC associated with being a successful intender. Women with fibromyalgia were motivated to walk; however, they did not act on their intentions, and PBC appeared as the main explanation. Women who perceived high control in comparison to those who perceived low control, increased their likelihood of adhering to a walking program about three-fold. Women with fibromyalgia should increase their perceived control through different strategies.

Goal Preferences, Affect, Activity Patterns and Health Outcomes in Women With Fibromyalgia.

Some motivational models understand health behavior as a result of the interaction between goal preferences and mood. However, this perspective has not been explored in fibromyalgia. Furthermore, in chronic pain, it has only been explored with regard to negative affect. Thus, our aims were: (1) to develop a Spanish version of the Goal Pursuit Questionnaire (GPQ); (2) to explore the relationships between goal preferences and health outcomes, testing the moderator role of affect and the mediating role of chronic pain activity patterns. We conducted two cross-sectional studies. In Study 1, after a double translation/back-translation process, we interviewed 94 women attending the Fibromyalgia Unit of the Community of Valencia in order to identify the cultural feasibility and the content validity of the GPQ. Study 2 comprised 260 women. We explored the GPQ structure and performed path analyses to test conditional mediation relationships. Eight activities from the original GPQ were changed while maintaining the conceptual equivalence. Exploratory factor analysis showed two factors: 'Pain-avoidance goal' and 'Mood-management goal' (37 and 13% of explained variance, respectively). These factors refer to patients' preference for hedonic goals (pain avoidance or mood-management) over achievement goals. Robust RMSEA fit index of the final models ranged from 0.039 for pain to 0.000 for disability and fibromyalgia impact. Pain avoidance goals and negative affect influenced pain mediated by task-contingent persistence. They also affected disability mediated by task and excessive persistence. Pain avoidance goals and positive affect influenced fibromyalgia impact mediated by activity avoidance. We also found a direct effect of negative and positive affect on health outcomes. Preference for pain avoidance goals was always related to pain, disability and fibromyalgia impact through activity patterns. Affect did not moderate these relationships and showed direct and indirect paths on health outcomes, mainly by increasing persistence and showing positive affect as an asset and not a risk factor. Intervention targets should include flexible reinforcement of achievement goals relative to pain avoidance goals and positive affect in order to promote task-persistence adaptive activity patterns and decreased activity avoidance.

Do women with fibromyalgia adhere to walking for exercise programs to improve their health? Systematic review and meta-analysis.

BACKGROUND: Walking is recommended for fibromyalgia, but the rate of adherence to this exercise is not known. Poor adherence to physical exercise can limit the effectiveness in health benefits. OBJECTIVES: To examine adherence to interventions that include walking for fibromyalgia and to explore its moderators among the characteristics of patients, of the walking prescription and of the interventions. DATA SOURCES: References from 2000 to 2016 have been collected through PubMed, PsycINFO, CINAHL, SPORTDiscus, Cochrane, and Teseo. STUDY SELECTION: We included quasi-experimental and randomized controlled trials in adults with fibromyalgia that involved walking for exercise. Two authors screened records independently and disagreements were resolved by discussion. DATA EXTRACTION: Independently extracted by two assessors. Methodological quality of the studies was assessed using an ad hoc scale. DATA SYNTHESIS: Nineteen trials, 32 experimental groups, recruited a total of 983 participants (96.78% women) with mean ages between 45 and 60.60. Adherence to the intervention program was reported in 19 of 32 experimental groups and ranged, on average, from 73 to 87.20% depending on the type of assessment. Most relevant moderators of adherence were the recruitment of participants through physicians and the nurses as supervisors of exercise. CONCLUSION: Adherence rates (attendance at sessions) to programs with walking were high. However, a lack of information precludes knowledge of whether participants sustained walking between sessions or after the treatment. Further work is required to examine in greater depth such contextual variables of interventions as the professional-participant relationship or to explore other possible moderators such as patient expectations of the treatment. Implications for rehabilitation Adherence to walking programs is more likely if doctors recommend the attendance at them. The combination with other activities may result in better adherence to walking than those that are only-walking exercise. The adherence to walking programs was larger in those in which nurses supervised the exercise. It is necessary to have adherence as objective, improving the record of adherence during treatment, assessing it between sessions and with a follow-up after the end of treatment.

What are the most representative warning signs of intimate partner violence against adolescent girls? / ¿Cuáles son las señales de alarma más representativas de la violencia de pareja contra las adolescentes?

Identifying which warning signs (WS) of intimate partner violence against girls (IPV) must be included in prevention programs is essential, since there is not an explicit consensus. Our first aim was identifying the most frequent WS included in the reviewed Spanish prevention guides by means of a content analysis performed independently by three judges. Our second aim was subjecting these to a sample of adolescents (n = 60) to know: (1) if they identify them as abusive behaviours; (2) how frequently do they consider they have to occur to be WS, and; (3) how frequently they observe them in their peer environment. Among the 23 identified WS, controlling (n = 11) and devaluating behaviours (n = 6) are the most frequent in the reviewed literature and the formers the most observed in the adolescents’ environment (rank: 52.5% - 90%). The majority labelled the 23 behaviours as abusive. Four controlling and 3 devaluating behaviours had to occur very often to be an IPV warning sign. Therefore their tolerance to these WS is high. The outcomes are valuable for the development of prevention programs and suggest the need of investigating on the explanatory factors of such tolerance

Identificar qué señales de alarma de violencia de género (VG) en la adolescencia deben incluirse en los programas de prevención es esencial. Al no existir un acuerdo explícito al respecto, nuestro primer objetivo fue identificar qué señales son más frecuentes en las guías de prevención españolas revisadas, mediante un análisis de contenido realizado independientemente por 3 juezas. Nuestro segundo objetivo fue valorar una muestra de adolescentes (n= 60) para conocer: (1) si las identifican como conductas violentas; (2) con qué frecuencia consideran que deben ocurrir para ser señales de alarma, y (3) con qué frecuencia las observan en su entorno de iguales. Entre las 23 señales identificadas, las conductas de control (n = 11) y desvalorización (n = 6) son las más frecuentes en la literatura revisada y prevalentes en los grupos de iguales (52.5% - 90%). La mayoría identificó las 23 conductas como violentas. Cuatro conductas de control y 3 de desvalorización tienen que darse a menudo para ser consideradas señales de alarma de VG. Por tanto, su tolerancia a las mismas es elevada. Estos resultados son útiles para la elaboración de programas de prevención y sugieren la necesidad de investigar sobre los factores explicativos de dicha tolerancia

The influence of academic discourses on medical students' identification with the discipline of family medicine.

PURPOSE: To understand the influence of academic discourses about family medicine on medical students' professional identity construction during undergraduate training. METHOD: The authors used a multiple case study research design involving international medical schools, one each from Canada, France, Spain, and the United Kingdom (UK). The authors completed the fieldwork between 2007 and 2009 by conducting 18 focus groups (with 132 students) and 67 semistructured interviews with educators and by gathering pertinent institutional documents. They carried out discursive thematic analyses of the verbatim transcripts and then performed within- and cross-case analyses. RESULTS: The most striking finding was the diverging responses between those at the UK school and those at the other schools. In the UK case, family medicine was recognized as a prestigious academic discipline; students and faculty praised the knowledge and skills of family physicians, and students more often indicated their intent to pursue family medicine. In the other cases, family medicine was not well regarded by students or faculty. This was expressed overtly or through a paradoxical academic discourse that stressed the importance of family medicine to the health care system while decrying its lack of innovative technology and the large workload-to-income ratio. Students at these schools were less likely to consider family medicine. CONCLUSIONS: These results stress the influence of academic discourses on medical students' ability to identify with the practice of family medicine. Educators must consider processes of professional identity formation during undergraduate medical training as they develop and reform medical education.

Family physicians' professional identity formation: a study protocol to explore impression management processes in institutional academic contexts.

BACKGROUND: Despite significant differences in terms of medical training and health care context, the phenomenon of medical students' declining interest in family medicine has been well documented in North America and in many other developed countries as well. As part of a research program on family physicians' professional identity formation initiated in 2007, the purpose of the present investigation is to examine in-depth how family physicians construct their professional image in academic contexts; in other words, this study will allow us to identify and understand the processes whereby family physicians with an academic appointment seek to control the ideas others form about them as a professional group, i.e. impression management. METHODS/DESIGN: The methodology consists of a multiple case study embedded in the perspective of institutional theory. Four international cases from Canada, France, Ireland and Spain will be conducted; the "case" is the medical school. Four levels of analysis will be considered: individual family physicians, interpersonal relationships, family physician professional group, and organization (medical school). Individual interviews and focus groups with academic family physicians will constitute the main technique for data generation, which will be complemented with a variety of documentary sources. Discourse techniques, more particularly rhetorical analysis, will be used to analyze the data gathered. Within- and cross-case analysis will then be performed. DISCUSSION: This empirical study is strongly grounded in theory and will contribute to the scant body of literature on family physicians' professional identity formation processes in medical schools. Findings will potentially have important implications for the practice of family medicine, medical education and health and educational policies.